Lessons from Indiana: the case for broader implementation of syringe exchange programs

Monica S. Ruiz, Sean T. Allen, & Allison O’Rourke

Abstract

This paper examines the recent HIV outbreak in Indiana and discusses the role of syringe exchange programs (SEPs) as effective interventions for HIV prevention in the US. We also briefly discuss the historical origins of legislation that govern SEP and how some of these policies impede broader implementation of this intervention. Finally, we present evidence for why these policies must change in order to more effectively contain the syndemic of HIV and substance use.

Introduction

In 2015, the United States experienced something it hadn’t seen for three decades: a HIV outbreak.

On February 25th, the Indiana State Department of Health reported a quickly growing HIV outbreak in rural Scott County. Thirty cases had been identified since mid-December 2014. Less than a month later, there were 68 cases. As of July 14, 2015, 174 cases were confirmed, the vast majority linked to injection of prescription opiates.

This outbreak of injection drug use (IDU)-associated HIV is a wakeup call about substance use in the US. The fact that the outbreak occurred in the rural Midwest, far away from urban centers typically associated as IDU hubs, highlights public misconceptions about where drug use occurs. It also highlights the importance of having comprehensive HIV prevention interventions, such as syringe exchange programs (SEPs), in geographically diverse locations. Unfortunately, wider SEP implementation is not possible due to policy restrictions at federal, state, and local levels.

This paper provides a brief overview of SEPs as effective interventions for HIV prevention in the US. We explore some of the policies that impede implementation and present evidence for why these policies must change in order to more effectively contain the syndemic of HIV and substance use.

Why needle and syringe exchange?

In 2011, 6% and 14% of new HIV infections in men and women (respectively) in the US were attributed to IDU. Although this is a significant decline in IDU-associated infections since the late 1980s, new cases are still diagnosed. Hepatitis C (HCV) risk is also significantly higher with IDU; data from 55 countries show HCV prevalence rates as high as 20-50% among persons who use injection drugs (PWID).

SEPs are a staple component of HIV prevention strategies based on the harm reduction model of behavior change, which “meets people where they’re at” in their addiction without requiring people to change behaviors before they are ready. This strategy is highly acceptable and highly effective in addressing the needs of marginalized populations., Further, studies show that SEPs are not associated with increased crime or illicit drug use.

The first SEPs in the US were established in the late 1980s. According to the North American Syringe Exchange Network (NASEN), there are 194 SEPs operating one or more sites in 33 states, the District of Columbia, the Commonwealth of Puerto Rico, and the Indian Nations. Since the implementation of SEPs, IDU-attributable HIV incidence in the US has declined by approximately 80%; this is the only category of adult HIV infection to show declines of this magnitude.

The politics of policy change for SEP

Policies affecting SEP implementation occur at multiple levels of government. Laws governing drug use and “paraphernalia” (i.e., injection equipment) possession –such as the Harrison Act of 1914 — were rooted in the perception of addiction as a criminal rather than public health issue. Many states passed their own paraphernalia laws, including policies restricting sales or distribution of sterile injection equipment. In some cases, state or municipal-level paraphernalia legislation was changed to allow SEP implementation. In other cases, policy changes were a direct response to public health crises, such as extraordinarily high HIV rates in PWID (e.g., Philadelphia, 1992) or evidence of a disease outbreak (e.g., Indiana).

There is Federal legislation specifically governing SEP. In 1988, Congress passed legislation prohibiting the use of federal monies to support SEPs. This legislation, known as the “Federal Ban”, was removed in 2009 and subsequently reinstated in 2012. During the two years in which the Ban had been lifted, only three US SEPs received federal funding. With the Ban’s reinstatement, restrictions on the use of federal monies apply to purchasing injection equipment as well as supporting personnel and delivery modes (e.g., vehicles) to distribute injection equipment. The Federal Ban remains despite the fact that the need for comprehensive prevention approaches for PWID is reflected in the National HIV/AIDS Strategy.

Washington, DC is in a class of its own with regard to legislation on SEP implementation, as both Federal and local-level legislation govern the city. In 1998, Congress proscribed the use of federal funds for SEP in the Financial Services Appropriations Bill. While this legislation did not affect states and localities, DC was affected due to Congress’ oversight of the city’s budget and operations through the Financial Services legislation. Thus, there were PWID in need of HIV prevention services, and DC was the only US city prohibited from using municipal revenue for SEPs. The “DC Ban” remained until December 2007, when a version of the 2008 Financial Services Bill without the Ban language was signed into law.

Ideally, the formation of any public policy should be rooted in rational interpretation of data, analysis of available policy options, and the consideration of the potential consequences. Policy analyses conducted a priori should inform policymakers on optimal policy option that has maximum cost-effectiveness, community level impact, political viability and sustainability, etc. Having said this, there are many — such as Meier and Bowen — who contend that this rational model of policymaking does not apply to the US’ policy on SEP. Bowen goes further, arguing that US drug policy as a whole is “a charged issue, largely driven by values and morals, instead of logic, economics, and principles of public health.” This irrationality extends to community-level policy decisions, manifested through “not in my backyard” ideologies that marginalize already disenfranchised groups, such as PWID, the homeless, and the mentally ill.

Our research on the use of research evidence as a foundation for policy change associated with SEPs in Baltimore (MD), Philadelphia (PA), and DC supports this idea. While morality arguments arose in each city context, the application of evidence to change policy was different in each city. In Baltimore and Philadelphia, research guided policy discussions and helped change policymakers’ and constituents’ conceptualizations about substance use and the utility of SEPs. In DC, the unwillingness of Congressional SEP opponents to consider research evidence proved to be a significant impediment. Several stakeholders described Congress as an “evidence-free zone” where SEP opponents misinterpreted research findings or took evidence out of context to support their opinions. One person commented, “…Whether you quoted from scientific journals…and…statistical evidence, from what was happening across the United States, none of it mattered.”

To our knowledge, no one has conducted a priori analyses to determine the soundness of changing legislation to allow SEP implementation. But could SEP policy be examined post hoc using some of the same criteria used in a priori analyses? Does SEP measure up in terms of two particularly important criteria – epidemic impact and cost effectiveness — for control of the HIV/AIDS epidemic?

Do SEPs have epidemic impact?

Research evidence overwhelmingly demonstrates that SEPs successfully reduce HIV incidence as well as injection-related practices that increase HIV and HCV risk. Data from the earliest SEPs are the most impressive: in Tacoma, SEPs were associated with an over 80% reduction in the incidence of hepatitis B and C infections. Similarly, SEPs were associated with a 33% reduction in HIV infection in New Haven, CT, and a 70% reduction in New York, NY.

While studies have examined changes in HIV incidence associated with the presence or absence of SEPs, our own research specifically looks at the epidemic impact of policy change – in this case, the DC Ban’s removal – as a naturally occurring policy intervention for HIV prevention for PWID. It is important to note that DC had a small, privately funded SEP during the time of the DC Ban so the examination of epidemic impact is not about the SEP’s presence or absence. The DC Ban’s removal was important because the policy change allowed for the allocation and use of resources to ramp up SEP services. We estimated that the policy change – and the services that were implemented as a result – averted 120 new infections in the first two years alone. Our findings not only provide support for SEP as an effective HIV prevention intervention, but also shed light on the role of poor public health policy as a determinant of HIV risk.

Are SEPs cost effective?

Abundant, compelling evidence supports SEPs’ cost-effectiveness. Numerous modeling studies show that widespread clean syringe access results in substantial financial savings compared to costs associated with lifetime HIV treatment.,,, Lurie and Drucker estimated that between 4,394 (15% incidence reduction) and 9,666 (33% incidence reduction) HIV infections could be averted as a result of implementing SEPs nationally, resulting in a $244 to $538 million (in 1997 USD) costs savings to the US healthcare system. Extrapolating to 2015 USD, the savings are approximately $361 to $796.5 million.

Our research found similarly impressive cost-savings. In the two years following the DC Ban’s removal, we estimated 120 averted HIV infections. The Centers for Disease Control and Prevention (CDC) estimated the average lifetime cost of treating HIV at $380,000 USD per person. Subtracting SEP operational costs, averting 120 cases of HIV translates to an approximate cost savings of $44.3 million USD. Given that the clinical care (including prescriptions) of many HIV-positive DC residents is covered by the city’s publicly funded health plan, costs saved in treatment are direct savings to DC taxpayers.

The way forward

The evidence discussed above is only a brief summary of SEP impact, as providing a comprehensive overview of such research is beyond the scope of this paper. Nonetheless, the data are clear that SEPs are an effective strategy for HIV prevention.

A compelling reason for the broader implementation of SEPs is the recent increase in abuse of prescription opioids, particularly in suburban and rural areas. These stories are seen both in the popular media, as well as the scientific literature. A 2012 study of 16-25 year old injectors found that initiation into prescription opioid misuse preceded the use of other illicit drugs such as heroin, and most surveyed injected their drugs. Given recent law enforcement crackdowns on prescription drug misuse, the transition from prescription opiates to cheaper, more easily accessible illicit drugs is inevitable. A recent Substance Abuse and Mental Health Services Administration (SAMHSA) report found that the number of people ages 12 and older who reported using heroin in the past year rose from 373,000 in 2007 to 681,000 in 2013, an 83% increase. While the report’s authors cannot verify that heroin use was a direct result of diversion from prescription opiate misuse, they cite information supporting the idea that individuals abusing pain relievers will switch to heroin due to decreased access to prescription drugs and lower relative cost.,

Which brings us back to Indiana. Acting on the Executive Order 15-05 issued by Governor Mike Pence, State Health Department officials were able to act quickly to establish a SEP in Scott County in less than 2 months since the initial news of the outbreak, overriding existing legislation declaring such programs to be illegal in the state. Through this Executive Order, Governor Pence showed that he could suspend his own views about needle exchange (he has previously voiced opposition to SEPs), focus on the research evidence supporting this intervention, and respond quickly to the public health need that mandated it. Further, by passing a measure that extends the legalization of SEPs for a year and expands services to any jurisdiction in the state that can prove an IDU-associated outbreak, the State Legislature is getting ahead of this outbreak rather than running after it. Such leadership needs to be noted and commended.

Larger scale SEP implementation mandates the removal of the Federal Ban. Even with no financial investment, the lifting of the Federal Ban would allow states to use federal monies to support HIV prevention services – including SEPs — that are most needed by communities. The potential benefit is increased with financial investment: a $10-$50 million increase in SEP funding would avert an estimated 194-816 HIV infections, with the cost savings per infection averted ranging from $51,601-$61,302, a high return on investment.

From Indiana, it is clear that the syndemic of drug addiction and HIV infection is real. If we are to combat these epidemics, we must put aside the personal and political biases that prevent the use of scientific evidence for public health benefit. The evidence on SEP effectiveness is clear and abundant. The public health need is evident and increasing.

What are we waiting for?

Acknowledgements

This work was supported by a grant from the National Institute on Drug Abuse (NIDA) to Monica S. Ruiz, PhD, MPH (R01DA031649). We also acknowledge the administrative support provided by the District of Columbia Center for AIDS Research (DC CFAR; P30AI087714). The authors of this paper have no conflicts of interest to declare.

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